The Psychopath Inside (2 page)

“W
hat is a psychopath?”

After viewing my brain scan—which, being a scientist, I considered more of a professional curiosity than a personal cause for alarm—I started asking my psychiatrist colleagues this question to see if I fit the bill. I asked some of the most preeminent researchers in the field, and yet I couldn't seem to get a satisfactory answer. Several dismissed the question, saying psychopaths didn't exist at all and that asking them to define
psychopath
was like asking them to define a nervous breakdown. It's a phrase people throw around, but it doesn't bear any scientific or professional meaning. (The same goes for
vegetable
, which is a somewhat arbitrary culinary term, not a biological one.) When I asked my friend Fabio Macciardi, a UCI colleague and a noted psychiatrist, he said, “There is no psychiatric diagnosis of
psychopath
.” After some pressing he explained, “The closest thing we have in the manual is a personality disorder, antisocial personality disorder. But that is not always the animal you're looking for, either.”

The manual Fabio was referring to is the
Diagnostic and
Statistical Manual of Mental Disorders
, most commonly referred to as the DSM. For psychiatrists and psychologists, this is the Bible—the book that outlines, defines, and classifies all disorders of the mind as agreed upon by the American Psychiatric Association and provides a standard of diagnosis that professionals are expected to follow. The DSM classifies a wide range of disorders from anorexia to schizophrenia, but psychopathy is not one of them. The definition for antisocial personality disorder, which Macciardi pointed to, is described as “a pervasive pattern of disregard for and violation of the rights of others that has been occurring in the person since the age of 15 years, as indicated by three (or more) of seven criteria, namely: a failure to conform to social norms; irresponsibility; deceitfulness; indifference to the welfare of others; recklessness; a failure to plan ahead; and irritability and aggressiveness.” Outside of the DSM, many doctors and researchers have their own definitions of what makes a psychopath. The problem is, every definition is different and none are cut-and-dried.

If one considers conventional medical standards of diagnosis, it's actually no wonder there is so much controversy surrounding psychopathy. For conditions like obesity, diabetes, and high blood pressure, it's easy to figure out whether a patient is afflicted, since the symptoms of these diseases are well-known and easy to test for. Do you have low levels of insulin, inhibiting your body's ability to metabolize sugar? You have diabetes. The same cannot be said for diseases of the mind.

For one thing, psychiatric diseases are not considered diseases at all. Diseases are based on knowledge of the cause (or
etiology) of a particular disorder and the effects (or pathophysiology) they have on the body. Unlike for many true diseases of other organ systems, we don't have this luxury with diseases of the mind since so little is known of the underlying pathological biological mechanisms at work. Despite advances in our understanding of how the brain works, the organ is still largely a mystery to us. Therefore, most psychiatric problems are called disorders or syndromes. Psychopathy stands on the lowest rung of this disease-disorder ladder, since no one agrees on what defines it—or if it exists at all—and so there is no professional agreement as to the underlying causes. Trying to identify or define psychopathy with just a checklist of traits and no cause is like using a field taxonomy guide. If it flies and eats and makes noises it could be a bird, but it could also be a bat or an insect; you haven't nailed down what the thing really is.

Although there are no set methods to test for psychiatric disorders like psychopathy, we can determine some facets of a patient's mental state by studying his brain with imaging techniques like PET (positron emission tomography) and fMRI (functional magnetic resonance imaging) scanning, as well as genetics, behavioral and psychometric testing, and other pieces of information gathered from a full medical and psychiatric workup. Taken together, these tests can reveal symptoms that might indicate a psychiatric disorder. Since psychiatric disorders are often characterized by more than one symptom, a patient will be diagnosed based on the number and severity of various symptoms. For most disorders, a diagnosis is also classified on a sliding scale—
more often called a spectrum—that indicates whether the patient's case is mild, moderate, or severe. The most common spectrum associated with such disorders is the autism spectrum. At the low end are delayed language learning and narrow interests, and at the high end are strongly repetitive behaviors and an inability to communicate.

Despite the debate about whether psychopathy is a real disorder and, if so, what defines it, there are some accepted parameters within the medical community. The most famous and widely used test is the PCL-R (Psychopathy Checklist, Revised), also known as the Psychopath Test or Hare's Checklist, named for the Canadian psychiatrist Robert Hare, who developed it. The PCL-R consists of twenty items, each of which is scored 0, 1, or 2, designating whether the psychopathic trait is not present (0 points), partially present (1 point), or definitely present (2 points). A person with a “perfect” score of 40 is a full-blown, categorical psychopath on this scale. Thirty is the normal cutoff for a diagnosis, although sometimes 25 is used. The test is scored by a person trained in giving the scale, usually during a session in which the clinician interviews the subject, sometimes supplemented with legal and medical records and third-person references. An evaluation can also be made by someone who knows the subject well, without his being present.

The traits can be sorted into four different categories, or “factors.” The interpersonal factor includes the traits of superficiality, grandiosity, and deceitfulness. The affective factor includes lack of remorse, lack of empathy, and refusal to accept
responsibility for one's actions. The behavioral factor includes impulsivity, lack of goals, and unreliability. And the antisocial factor includes hotheadedness, a history of juvenile delinquency, and a criminal record. Antisocial personality disorder is related to psychopathy but is much more common and is a measure of outward disruptive behavior rather than an underlying personality problem. Psychopathy scores are actually a better predictor of criminal recidivism, severity, and premeditation.

Psychopathy is not something one can just casually assess, although there are versions of the test that can be self-administered and are not “officially” diagnostic. A typical statement on a self-administered checklist might be, “I can be shrewd, crafty, sly, and clever—if needed, I can also be deceptive, unscrupulous, underhanded, manipulative, and dishonest.” Two other sample statements would be, “At times, I feel a strong need for novel, thrilling, and exciting stimulation; I get bored easily. This might result in me taking chances and doing things that are risky. Carrying tasks through ‘to the bitter end' or staying in the same job for a longer time can feel very difficult for me,” and “Significant amounts of the money I have made, I have made by intentionally exploiting or manipulating others. With ‘classic' forms of work, I often feel a lack of motivation, a problem with my self-discipline, or an inability to complete my responsibilities.”

To illustrate the degrees represented on the PCL-R, I like to point to pop culture, which is full of portrayals—some accurate, some less so—of psychopaths. The most extreme and ridiculous examples can be found in horror films featuring foul-toothed
characters with one foggy eyeball who exude danger and immediately evoke chills. Think Freddy Krueger or the family in
The Texas Chain Saw Massacre
. Even Patrick Bateman, Christian Bale's self-loving, unhinged character in the film adaptation of
American Psycho
, is not representative of a true psychopath, as he is too violent to be realistic. These are caricatures—even the most violent criminals are rarely so obviously insane.

Some reasonable characterizations include Tommy DeVito, played by Joe Pesci in
Goodfellas
,
and Frank Booth, played by Dennis Hopper in
Blue Velvet
. Both of these are relatively normal-looking guys—guys you might pass on the street and not think twice about. But they are deeply disturbed individuals who ultimately cannot control their innate aggressiveness and show little regret or sympathy for their violent actions. Tommy and Frank would score high on the PCL-R. Tommy in particular expresses the interpersonal aspects of glibness, charm, and manipulation. He's entertaining, and he can go in and out of character. In the “Do I amuse you?” exchange, he has the other guy pinned—there's no right answer. Psychopaths can put people into untenable positions. There's also a scene in which Tommy shoots a guy in the foot, then curses him out for making a big deal of it and goes back to playing cards. After a murder, psychopaths often say they feel like someone else did it, or the victim precipitated the pulling of the trigger. They feel detached, impelled to action by forces out of their control. Tommy calls the foot-shooting incident an “accident.” Not all psychopaths are impulsive or physically violent, but some are, as in the cases of Tommy and Frank.

My favorite example comes from the 1986 film
Manhunter
, starring Brian Cox and William Petersen. Cox plays Hannibal Lecter, a cannibalistic serial killer who was later reprised more famously by Anthony Hopkins in the films
The Silence of the Lambs
and
Hannibal
. Lecter is characterized by his lack of empathy, his glib and charming manipulation of people, and his utter lack of remorse for his horrid and perverse behaviors. In short, he is what many would consider a classic psychopath and would probably have scored high on Hare's Checklist. Real-life psychopaths who resemble Lecter account for the more sensational and extreme cases—think Jeffrey Dahmer, Ted Bundy, or the Son of Sam.

But according to Hare, there is an entire other category of psychopaths out there—those who don't score as high on the PCL-R but who still exhibit strong signs of classic psychopathic traits. These are people like the hero of
Manhunter
, the FBI profiler Will Graham, played by Petersen. Graham recognizes that he has the same urges and lack of interpersonal empathy as Lecter. Although he is not a murderer, he is, in fact, a psychopath, or at least a near-psychopath, what I like to call Psychopath Lite. He might score a 15 or 23 on the PCL-R, just under the 30-point score cutoff for full psychopathy, but other than that, you might think him completely normal. When my wife, Diane, and I saw the film in 1986, she pointed to Will and said, “That is you.” (At the time, it threw me off a bit, but I decided she was referring to how nice and deep a guy Will was.)

Full-blown, categorical psychopaths—those who score 30 or more—make up only about 1 percent of females and 3 percent of
males who have taken the test. But despite—or perhaps because of—its broad classification system, Hare's scale has been hotly contested, as usually happens in a new field of medicine or science. Every scientific meeting, every casual conversation in hallways and bars among colleagues in widely divergent fields, inevitably leads to an argument over the nature of the condition.

One critique is that the scale doesn't take into consideration class and ethnicity. What's normative behavior in a crime-ridden lower-class neighborhood in downtown L.A. is different from that in an upper-class neighborhood in Minnesota. There are also debates about how well it predicts violence. Märta Wallinius and collaborators at the Swedish universities of Lund, Gothenburg, and Uppsala showed in 2012 that the antisocial facet (hotheadedness, etc.) predicts violent behavior particularly well, but the interpersonal aspect (superficiality, etc.) doesn't predict it at all. The criminal justice system is especially interested in such findings.

Despite the controversy over whether psychopaths exist, psychiatrists generally agree that one of the defining characteristics of those we refer to as psychopaths is the lack of interpersonal empathy, what one might call a flat emotional playing field. Psychopaths may not hate, but they also may not love the way most of us would prefer to love and be loved. Psychopaths are usually manipulative, are champion liars, and can be quite glib and disarmingly charming. They don't fear consequences the way most people do, and while they may react to the stress of being caught in a lie or violent act like anyone would, some remain cool as cucumbers. Even the most dangerous can appear jovial, carefree, and
social at times, but sooner or later they will display a telling distance, a quiet coldheartedness and disregard for others. They are often impulsive, yet lack guilt and remorse, meaning they may invite you to join in on their reckless, even dangerous fun, and then shrug their shoulders if someone gets hurt.

In identifying a psychopath, the Hare Checklist is a good start, but it's not perfect. Rather than adding up twenty traits, each with a value of 0, 1, or 2, I would score them each from 0 to 5, and use a mathematical model to give each trait a different weight. Even better, each person would have an individualized profile rather than a single numerical score or a categorical yes-or-no diagnosis. You can't judge health or obesity on height and weight alone. Are you exercising? What are you eating and drinking? You can be overweight but in great shape. A doctor who knows you well would take all of that into account.

It's also difficult to summarize a collection of behaviors as one disorder. There's a lot of overlap between conditions, such as histrionic, narcissistic, and antisocial personality disorders. And everyone is a little bit psychopathic and has a little bit of ADHD and so on. Psychiatry is moving away from categorical thinking—the latest diagnostic manual talks about “dimensions” to disorders—but it's hard when doctors don't want to learn new methods, insurance companies need to rely on specific diagnoses, and everyone likes closure and clearly defined labels. I see psychopathy like others see art; I can't define it, but I know it when I see it.